title: The effects of temporally secondary co-morbid mental disorders on the associations of DSM-IV ADHD with adverse outcomes in the US National Comorbidity Survey Replication Adolescent Supplement (NCS-A).
abstract: BACKGROUND
  Although DSM-IV attention deficit hyperactivity disorder (ADHD) is known to be associated with numerous adverse outcomes, uncertainties exist about how much these associations are mediated temporally by secondary co-morbid disorders.
  
  
  METHODS
  The US National Comorbidity Survey Replication Adolescent Supplement (NCS-A), a national survey of adolescents aged 13-17 years (n = 6483 adolescent-parent pairs), assessed DSM-IV disorders with the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). Statistical decomposition was used to compare direct effects of ADHD with indirect effects of ADHD through temporally secondary mental disorders (anxiety, mood, disruptive behavior, substance disorders) in predicting poor educational performance (suspension, repeating a grade, below-average grades), suicidality (ideation, plans, attempts) and parent perceptions of adolescent functioning (physical and mental health, interference with role functioning and distress due to emotional problems).
  
  
  RESULTS
  ADHD had significant gross associations with all outcomes. Direct effects of ADHD explained most (51.9-67.6%) of these associations with repeating a grade in school, perceived physical and mental health (only girls), interference with role functioning and distress, and significant components (34.5-44.6%) of the associations with school suspension and perceived mental health (only boys). Indirect effects of ADHD on educational outcomes were predominantly through disruptive behavior disorders (26.9-52.5%) whereas indirect effects on suicidality were predominantly through mood disorders (42.8-59.1%). Indirect effects on most other outcomes were through both mood (19.8-31.2%) and disruptive behavior (20.1-24.5%) disorders, with anxiety and substance disorders less consistently important. Most associations were comparable for girls and boys.
  
  
  CONCLUSIONS
  Interventions aimed at reducing the adverse effects of ADHD might profitably target prevention or treatment of temporally secondary co-morbid disorders.
authors.affiliation: Department of Health Care Policy, Harvard Medical School, Boston, MA, USA.
authors.forename: R C
authors.initials: RC
authors.lastname: Kessler
authors.affiliation: Departments of Psychiatry and Child and Adolescent Psychiatry, NYU School of Medicine and Psychiatry, NY VA Harbor Healthcare Service, New York, NY, USA.
authors.forename: L A
authors.initials: LA
authors.lastname: Adler
authors.affiliation: University of Michigan, Institute for Social Research, Ann Arbor, MI, USA.
authors.forename: P
authors.initials: P
authors.lastname: Berglund
authors.affiliation: School of Education, Boston University, Boston, MA, USA.
authors.forename: J G
authors.initials: JG
authors.lastname: Green
authors.affiliation: Division of General Pediatrics, Children's Hospital Boston, Harvard Medical School, Boston, MA, USA.
authors.forename: K A
authors.initials: KA
authors.lastname: McLaughlin
authors.affiliation: Institute for Development Research, Advocacy, and Applied Care (IDRAAC), St George Hospital University Medical Center, Beirut, Lebanon.
authors.forename: J
authors.initials: J
authors.lastname: Fayyad
authors.affiliation: Shire Development Inc., Wayne, PA, USA.
authors.forename: L J
authors.initials: LJ
authors.lastname: Russo
authors.affiliation: Department of Health Care Policy, Harvard Medical School, Boston, MA, USA.
authors.forename: N A
authors.initials: NA
authors.lastname: Sampson
authors.affiliation: Department of Health Care Policy, Harvard Medical School, Boston, MA, USA.
authors.forename: V
authors.initials: V
authors.lastname: Shahly
authors.affiliation: Department of Health Care Policy, Harvard Medical School, Boston, MA, USA.
authors.forename: A M
authors.initials: AM
authors.lastname: Zaslavsky
mesh_terms: D000293:Adolescent; D001289:Attention Deficit Disorder with Hyperactivity / Q000150:complications / Q000453:epidemiology*; D015897:Comorbidity; D039721:Diagnostic and Statistical Manual of Mental Disorders; D005260:Female; D006801:Humans; D008297:Male; D001523:Mental Disorders / Q000453:epidemiology*; D015995:Prevalence; D013405:Suicide / Q000706:statistics & numerical data; D014481:United States / Q000453:epidemiology